Maternity / Newborn Nursing PQs

B. Discontinue the oxytocin infusion — the patient is experiencing uterine tachysystole, and oxytocin will increase contractions. Need to remove oxytocin to prevent fetal distress.

A client at 39 weeks gestation is receiving oxytocin for labor induction. The fetal heart tracing shows a baseline of 70 BPM, minimal variability, and recurrent late decelerations. Contractions occur every 90 seconds and last 100 seconds. Which action should the nurse take first?

A. Apply oxygen at 10 L/min by non-rebreather mask

B. Discontinue the oxytocin infusion

C. Perform a vaginal examination

D. Notify the obstetric provider

C. Concealed hemorrhage may be causing maternal shock and fetal compromise — placental abruption is strongly suggested by the findings

A client at 35 weeks gestation arrives with sudden severe abdominal pan. The uterus is firm and tender, the FHR is 95 BPM, and only a small amount of dark vaginal blood is visible. The client’s BP is 88/54 mmHg and heart rate is 124 BPM. Which interpretation is most accurate?

A. The amount of visible blood suggests that maternal blood loss is minimal

B. The client is probably experiencing placenta previa

C. Concealed hemorrhage may be causing maternal shock and fetal compromise

D. The fetal bradycardia is most likely caused by fetal head compression.

B. Massage the fundus — findings indicate uterine atony, thus fundal massage is first nursing intervention

A postpartum nurse notes that a client has heavy vaginal bleeding and a boggy uterus. What should the nurse do first?

A. Call the HCP

B. Massage the fundus

C. Obtain vital signs

D. Administer pain medication

C. Place the client in the left lateral position — late decels indicate placental insufficiency, so think LION

The nurse observes late decelerations on the fetal monitor. What is the nurse’s priority action?

A. Continue monitoring

B. Encourage the client to push

C. Place the client in the left lateral position

D. Increase oxygen

C. Provide routine initial newborn care while continuing assessment — the newborn is not compromised and routine endotracheal suctioning is not indicated

A newborn is delivered through meconium-stained amniotic fluid. The newborn has a strong cry, good muscle tone, and a heart rate of 148 BPM. Which action is most appropriate?

A. Perform routine endotracheal suctioning before drying the newborn

B. Begin chest compressions because meconium is present

C. Provide routine initial newborn care while continuing assessment

D. Delay skin-to-skin contact until gastric suctioning is completed

C. Severe headache with blurred vision — warning signs of preeclampsia

A nurse is assessing a client at 30 weeks gestation. Which finding should the nurse report to the HCP immediately?

A. Mild ankle edema at the end of the day

B. Urinary frequency

C. Severe headache with blurred vision

D. Heartburn after meals

A. Breasts

B. Uterus

D. Lochia

E. Extremities

F. Emotions

A nurse is caring for a postpartum client using the BUBBLE-LE assessment. Which assessments are included? (select all that apply)

A. Breasts

B. Uterus

C. Lungs

D. Lochia

E. Extremities

F. Emotions

D. A client in labor with recurrent late decelerations, minimal variability, and a uterus that does not relax between contractions — suggest placental insufficiency, need to enact LION

The nurse receives reports on four clients. Which client should be seen first?

A. A client 6 hrs postpartum with a firm fundus, lochia rubra, and a temp of 37.7°C.

B. A client at 38 weeks gestation with painless vaginal bleeding who has stable vital signs and a reassuring fetal tracing.

C. A client receiving magnesium sulfate who has a respiratory rate of 12/min, present reflexes, and a urine output of 40 mL/hr.

D. A client in labor with recurrent late decelerations, minimal variability, and a uterus that does not relax between contractions.

A. Heart rate increase from 88 to 118 BPM

B. Urine output decreases to 15 mL/hr

C. The client reports increasing anxiety and restlessness

E. Skin becomes pale, cool, and clammy

A postpartum client is receiving oxytocin for uterine atony. despite fundal massage and an empty bladder, the uterus remains boggy and bleeding continues. Which findings should the nurse identify as evidence of worsening hypovolemia or impaired perfusion? (select all that apply)

A. Heart rate increase from 88 to 118 BPM

B. Urine output decreases to 15 mL/hr

C. The client reports increasing anxiety and restlessness

D. Blood pressure changes from 118/74 to 110/70 mmHg

E. Skin becomes pale, cool, and clammy

F. The fundus descends approximately 1 cm per day

B. Placenta previa

A laboring client has painless bright-red vaginal bleeding. Which complication should the nurse expect?

A. Placental abruption

B. Placenta previa

C. Uterine rupture

D. Ectopic pregnancy

C. 26 cm — after 20 weeks, fundal height = gestational age ± 2 cm

Your patient is 24 weeks pregnant, and you’re measuring the fundal height. Which finding below is the normal measurement for this patient?

A. 16 cm

B. 28 cm

C. 26 cm

D. 12 cm

D. 8

Indicator (APGAR)	0	1	2
Appearance  (skin color)	Blue pale	Pink body, blue extremities	Pink
Pulse	Absent	<100 BPM	>100BPM
Grimace	Floppy	Minimal response to stimuli	Prompt response to stimuli
Activity	Absent, flaccid	Some flexion	Arms and legs flexed
Respirations	Absent	Slow and irregular	Vigorous cry

The nurse is collecting the 1 minute APGAR score on a newborn. She notes the heart rate to be 140 BPM, the cry is strong and regular, the body is pink with slightly blue hands, and there is some flexion to the arms and legs. While assessing the newborn, it moves and cries. What is the newborn’s APGAR?

A. 5

B. 9

C. 6

D. 8

B. head compression — remember VEAL CHOP

Early decelerations are noted on the fetal heart monitor. The nurse knows that ________ is the cause of this finding.

A. uteroplacental insufficiency

B. head compression

C. cord compression

D. prolapsed uterus

D. The baby’s presenting part is 2 cm below the ischial spine

During assessment of a laboring woman, it is noted that the fetal station is +2. The nurse interprets this to mean?

A. The baby’s presenting part is 2 cm above the iliac spine

B. The baby’s presenting part is 2 cm below the iliac spine

C. The baby’s presenting part is 2 cm above the ischial spine

D. The baby’s presenting part is 2 cm below the ischial spine

B. 2 cm below the umbilicus — fundal height should decrease by 1 cm/day below the belly button.

Your patient is 48 hours postpartum. While assessing fundal height, you would expect the fundal height to be?

A. 1 cm above the umbilicus

B. 2 cm below the umbilicus

C. 2 cm above the umbilicus

D. 1 cm below the umbilicus

Fasting: 94 mg/dL = normal

1 hour: 210 mg/dL = abnormal

2 hours: 180 mg/dL = abnormal

3 hours: 130 mg/dL = normal

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Normal Reference Ranges for 3 Hour Glucose Testing:

Fasting < 94

1 hour <180

2 hour <155

3 hour <140

A patient who is 27 weeks pregnant has a 3 hour glucose tolerance test performed. Below are the results. Interpret the results as either normal or abnormal.

Patient’s Report:

• Fasting: 94 mg/dL = ________

• 1 hour: 210 mg/dL = ________

• 2 hours: 180 mg/dL = ________

• 3 hours: 130 mg/dL = ________

A. Gravida 1, para 1 — she had one pregnancy (gravida) and it was full term (parity)

A 28 year old patient gives birth to twins at 38 weeks gestation. This is the patient’s first pregnancy. Which of the following best describes the patient’s gravidity and parity?

A. Gravida 1, para 1

B. Gravida 1, para 2

C. Gravida 2, para 2

D. Gravida 1, para 0

D. Calcium gluconate — antidote for magnesium sulfate toxicity

A patient with preeclampsia is started on magnesium sulfate. The nurse knows to have what medication on standby while the patient is receiving this medication?

A. Acetylcysteine

B. Oxytocin

C. Calcium carbonate

D. Calcium gluconate

May 22, 2017 — formula: LMP + 7 days − 3 months + 1 year

During a prenatal visit, a patient tells you her last menstrual period was August 15, 2016. Based on the Naegele’s Rule, what is the estimated due date of her baby?

B. Hard abdomen

C. Fetal distress

E. Tender uterus

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Think DETACHED when placental abruption is occuring

Dark red bleeding
Extended fundal height
Tender uterus
Abdominal pain/cramping
Concealed bleeding
Hard abdomen
Experiences DIC
Distressed baby

A 36 year old patient who is 38 weeks pregnant reports having dark red bleeding. The patient experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms are likely to present with abruptio placentae? (select all that apply)

A. Decrease in fundal height

B. Hard abdomen

C. Fetal distress

D. Abnormal fetal position

E. Tender uterus

B. Quickening

A 25 year old patient who is 18 weeks pregnant reports feeling fluttering in the lower abdomen. The patient states it feels like the baby is moving. This is known as:

A. Ballottement

B. Quickening

C. Hegar’s Sign

D. Goodell’s Sign

B. Hegar’s sign

A patient presents with a possible pregnancy. During an examination, it is noted that the patient has softening of the cervix. This is known as what probable signs of pregnancy?

A. Goodell’s sign

B. Hegar’s sign

C. Chadwick’s sign

D. Palmer’s sign

A. Perform fundal massage and assist the patient to the bathroom

You are performing a routine assessment on a mother post delivery. The uterus is soft and displaced to the left of the umbilicus. What is your next nursing action?

A. Perform fundal massage and assist the patient to the bathroom.

B. Continue to monitor the mother. This is a normal postpartum finding.

C. Notify the HCP.

D. Administer PRN dose of pitocin (oxytocin) as ordered by the HCP

B. Changing positions and walking does not decrease comfort

C. The contractions are regular

D. The cervix is effaced 90% and dilated to 4 cm

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True Labor

• Contractions are regular

• Radiating contraction pain

• Unable to relive contraction pain w/ activity

• Exam changes present

False Labor

• Fails to change cervix and baby position

• Activity diminishes contractions

• Keep feeling contractions above navel/umbilicus

• Erratic timing of contractions

A patient who is 39 weeks pregnant arrives to labor triage. The patient’s prenatal history includes gravidity 3, parity 2. What signs and symptoms below indicate the patient is experiencing true labor? (select all that apply)

A. The patient states the contractions are located above the umbilicus

B. Changing positions and walking does not decrease comfort

C. The contractions are regular

D. The cervix is effaced 90% and dilated to 4 cm